Application for Hardship Waiver - California

State of California¡ªHealth and Human Services Agency

Department of Health Care Services

Application for Hardship Waiver

Submission of this application is necessary to apply for a waiver of the claim due to substantial

hardship. Only the applicant's proportionate share of the claim can be waived. An applicant has

60 days from the date stated on the Department of Health Care Services¡¯ (Department) notice of

claim in which to submit an application. All of the information requested in the application is

voluntary; however, failure to completely and accurately provide the information may result in a

denial of the waiver application.

A substantial hardship shall not exist when the decedent or applicant created the hardship by

using estate planning methods to divert or shelter assets in order to avoid estate recovery.

A. ESTATE OF:

Case Number:

Total Value of Estate:

Claim Amount:

A. ESTATE OF:

Total Value of Estate:

Case Number:

Date of Application:

Date of Application:

Claim Amount:

Your Share of Estate: (50%, 75%, 100% etc). Attach a copy of the Will or Trust

Your Share of Estate: (50%, 75%, 100% etc). Attach a copy of the Will or Trust

Your Share of Estate: (50%, 75%, 100% etc).

Attach a copy of the Will or Trust

==================================================================================================

Middle,Middle,

Last): Last): Social

Social

Security

Driver's

License/ID

Birth

Date

(m/d/y):

Social

Security

Number: Number:

License/ID

Number: Number:

Date

(m/d/y):

B. APPLICANT¡¯S NAME (First,

Security

Number: Driver's

Driver's

License/ID

Number: Birth

Birth

Date

(m/d/y):

Social Security

Driver's License/ID Number:

Birth Date

B.APPLICANT¡¯S

APPLICANT¡¯S

NAME

B.

NAME (First,

Middle,(First,

Last):

Number:

(m/d/y):

Relationship

to decedent:

Relationship

to decedent:

Street

Address:

Street

Address:

Street

Address:

City:

City:

City:

State:

State:

State:

Telephone

Number:Number:

Telephone

Number:

Telephone

Zip:

Zip:

Zip:

(

P. O. Box

City:

P. O. Box

P.O. Box

State:

City:

City:

Spouse's Name (First, Middle, Last):

Applicant¡¯s Employer:

Applicant¡¯s Employer:

Applicant's

Zip:

Zip:

State:

State:

Zip:

Social Security Number:

Spouse's Name (First, Middle, Last):

Spouse's Name (First, Middle, Last):

Social Security Number:

Social Security Number:

DateDate

(m/d/y):(m/d/y):

Driver's License/ID Number: Birth

Birth

Birth Date (m/d/y):

Driver's License/ID Number:

Driver's License/ID Number:

Address:

Address:

City/State/Zip:

City/State/Zip

City/State/Zip

Telephone Number:

Telephone Number

Address:

Address:

Address:

City/State/Zip

City/State/Zip:

City/State/Zip

Telephone Number:

Telephone

Address:

Telephone Number

(

)

Employer:

Spouse's

Employer:

Spouse's

Employer:

Spouse's

Employer:

)

Telephone Number:

(

)

Number:

Yes

Are there any unmarried children, or any other persons, living with the applicant?Yes

Yes (

Are there any unmarried children, or any other persons, living with the applicant?

Are there any unmarried children, or any other persons, living with the applicant?

Yes

No

) No

No

(

No

)

Ifyes,

yes,

listname,

their

name,

birth

date,

and

relationship

to applicant.

If

name,

birth

date,

and

relationship

to applicant.

If yes,

list list

their their

birth

date, and

relationship

to applicant.

Please

include

anyorrent

or household

contributions

made to

the applicant

Please

include

any rent

household

contributions

made to the applicant

Section

E.

Please include any rent or household contributions made

to the

Section

E. applicant Section E.

Name

(First,

Middle, Last):

Last):

Name

Middle,

Name

(First,(First,

Middle,

Last):

Birth Date (m/d/y):

Name

(First,

Middle,

Name

(First,

Middle,

Last):

Name

(First,

Middle,

Last):

Birth

(m/d/y):

BirthDate

Date

(m/d/y):

Last):

Name

(First,

Last):

Name

(First,

Middle,

Last):

Name

(First,

Middle,Middle,

Last):

DHCS 6195 (8-07)

Birth Date

Date (m/d/y):

Birth

(m/d/y):

Relationship

to applicant:

applicant:

Relationship

to

Relationship

to applicant:

Birth Date (m/d/y):

Relationship

to applicant:

Relationship

to applicant:

Relationship to applicant:

Birth

Date

(m/d/y):

Birth

Date

(m/d/y):

Birth

Date

(m/d/y):

Relationship

to to

applicant:

Relationship

applicant:

Relationship

to applicant:

1

State of California¡ªHealth and Human Services Agency

Department of Health Care Services

C. Criteria for Hardship Waiver consideration can be found in the California Code of Regulations, Section 50963.

Please check the criteria below that qualifies the applicant for a hardship waiver. Attach documentation that

provides substantiation for the criteria selected. Failure to provide sufficient substantiation may result in a

denial of the waiver.

(

) Receiving the inheritance from the estate will enable the applicant to discontinue eligibility for public assistance

payments and/or medical assistance programs.

(

) The estate property is part of an income-producing business, including a working farm or ranch, and recovery of

medical assistance expenditures would result in the applicant losing his or her primary source of income.

(

) The applicant is aged, blind, or disabled and has continuously lived in the decedent's home for at least one year prior to

the decedent¡¯s death and continues to reside there, and is unable to obtain financing to repay the State. The applicant

shall apply to obtain financing, for an amount not to exceed his or her proportionate share of the claim, from a financial

institution as defined in Probate Code Section 40. The applicant shall provide the Department with a denial letter(s)

from the financial institution.

(

) The applicant provided care to the decedent for two or more years that prevented or delayed the decedent¡¯s admission

to a medical or long-term care institution. The applicant must have resided in the decedent¡¯s home during the period

care was provided and continue to reside in the decedent¡¯s home. The applicant must provide written medical

substantiation from a licensed health care provider(s), which clearly indicates that the level and duration of care

provided prevented or delayed the decedent from being placed in a medical or long-term care institution.

(

) The applicant transferred the property to the decedent for no consideration.

(

) The equity in the real property is needed by the applicant to make the property habitable, or to acquire the necessities of

life, such as food, clothing, shelter or medical care.

D. DECEDENT¡¯S ESTATE CONSISTS OF: Check all applicable assets and complete all related information.

List all estate assets including property conveyed through joint tenancy, tenancy in common, life estate, living,

trust, annuities purchased on or after September 1, 2004, life insurance policy, or retirement account. Please

attach copies of recorded deed(s), registration(s), bank statement(s), listing agreements/contracts, life insurance

policy statements, stocks, bonds, and annuity documentation, etc.

Market

Market Value

$

Market Value $

Market Value $

Value $

(

) Real

Real

Property

Property

Real

Property

____________

(

Mobile

Home

Mobile

Home

) Mobile Home

____________

Is the

Is the property listed for

sale? Yes

YesYes (

) NoNoNo (

)

Yes

property

If

no,

If no, Please explain.

listed for

Please

_______________________________________________

Mortgage Owed $

Mortgage Owed $

Mortgage Owed

Is the property listed for sale?

Is the property listed for sale?

If no, please explain.

If no, Please explain.

$

______________

sale?

explain.

______________

Estate Property Street Address:

Estate Property Street

City:

City:

Estate Property Street Address:

State:

State:

City:

State:

Zip:

Zip:

Zip:

Address:

Is anyone living in the property?

Is anyone living in the property?

Yes

Yes

Yes

Is anyone living in the property?

Yes (

) No

No (

No

No

)

Amountofofmonthly

monthly

rentcollected?

collected?

Is the property being rented? Amount

monthly

rent

collected?

Amount

ofofmonthly

rent

collected?

Amount

rent

Is the property being rented?

Is the property being rented?

If yes, how long have they lived in the property?

If yes, how long have they lived in the property?

If yes, how long have they lived in the property?

___________________________________________

Name

and relationship

to decedent (if any) to decedent (if any).

Name

and relationship

Name and relationship to decedent (if

any).

Are

paying

spacespace

rent for the

mobile

home?

Areyouyou

paying

rent

for the

mobile

home?

Are you paying space rent for the mobile home?

Yes

Yes

Yes (

) No

No (

No

)

If

If yes,

yes, how

how much?

much? (Attach

(Attach statement)

statement)

the estate

estate property

property held

IsIs the

heldininaatrust?

trust?

Yes

Yes

No

) No

No (

)

Type

of of

trust?

(Attach

copy

of Trust

document)

Type

(Attach

copy

of Trust

document)

Type

oftrust?

trust?

(Attach

copy

of Trust

document)

Yes (

Is

Is this

this estate

estate property

property part

part of

of an

an income

income producing

producing business,

business, including

including a

a working

working farm

farm or

or ranch?

ranch?

If yes, how much? (Attach statement)

Yes

Is this estate property part of an income producing business, including a working farm or ranch? Yes

(

Yes

(

)

No

(

)

Yes

Yes

No

Yes

No

(PleaseSection

include

income in Section E.)

income

E.)

(Pleasein include

income in Section E.)

Name

Address

of Bankof Bank

Name

&

Address

of

( ) Bank

Bank

Account Checking

$

Savings

$

Name

& Address

Savings

$$

Savings

Name

&&

Address

of Bank

Bank

Bank

BankAccount

Account

Checking

Checking $

$

Savings

$

)

No

No

No (

)

If

isisthis

your

primary

source

of source

income?

(Please

include

yes,

isthis

this

your

primary

of income?

IfIfyes,

yes,

your

primary

source

of income?

Account

Number

Account

Number

Account

Number

Account Number

Account

(

) Annuities

Annuities

Annuities

(

Life

Estate

) Life

Life

Estate

Estate

DHCS 6195 (8-07)

Value $

Value

Value $$

Value $

Value $

Value $

Value $

Type

Date Purchased

Type

Type

Type

Date

Purchased

Date

Date

Purchased

Purchased

Type

Type

Type

Type

2

State of California¡ªHealth and Human Services Agency

(

Life

LifeInsurance

InsurancePolicy

Policy

) Life Insurance Policy

Value $

Value $

Beneficiary(s)

Beneficiary(s)

Value $

Value $

Beneficiary(s)

Beneficiary(s)

Beneficiary(s)

Type

Value $

Value $

Type

Type

Date Purchased

Date Purchased

Value $

Retirement

Accounts

( ) Retirement

Retirement

Accounts

Retirement

Accounts

(IRA/Other)

Accounts

IRA/Other)

(IRA/Other)

(

Department of Health Care Services

Beneficiary(s)

Value $

Stocks/Bonds/Notes/Other

) Stocks/Bonds/Notes/Other

Stocks/Bonds/Notes/Other

Stocks/Bonds/Notes/Other

Value $

Type

Type

(CDs/IRA/ROTH/IRA/Other)

(CDs/IRA/ROTH

(CDs/IRA/ROTH)

Date Purchased

APPLICANT¡¯S

MONTHLY

INCOME.

Please

attach

copy

most

recent

federal

state

income

return

E.E.

APPLICANT¡¯S

MONTHLY

INCOME. Please

attach copy

of most

recent

federal

and

state

income

tax federal

return

E.

APPLICANT¡¯S

MONTHLY

INCOME.

Please

attach

copy

of of

most

recent

andand

state

income

tax tax

return

Applicant¡¯sNet

NetPay

Pay(Attach

(Attachtwo

two months

months most

Applicant¡¯s

most recent

recentpay

paystubs)

stubs)

$______________________

(If not monthly, please indicate weekly, bi-weekly, etc.)

(If not monthly, please indicate weekly, bi-weekly, etc.)

Spouse¡¯s

NetNet

Pay

(Attach

two

months

mostmonths

recent

paymost

stubs)recent

(If

notstubs)

Monthly,

please

Spouse¡¯s

Net

Pay

(Attach

pay (If

stubs)

Spouse¡¯s

Pay

(Attach

two two

months

most

recent

pay

not indicate

$______________________

(If not

monthly,

weekly,

bi-weekly,

etc.)please indicate weekly, bi-weekly, etc.)

monthly,

please

indicate weekly, bi-weekly, etc.)

Rents

Paid

to Applicant

Applicant

(Please

provide

rental

Rents

Paid

to Applicant

(Please

provide

rental agreement)

Rents

Paid

to

(Please

provide

rentalagreement)

agreement)

Social

Security/Retirement/Pensions/Annuities

(Attach

two most

recent

Social

Security/Retirement/Pensions/Annuities

(Attach two

most (Attach

recent

stubs)

Social

Security/Retirement/Pensions/Annuities

two

moststubs)

recent

$______________________

stubs)

$______________________

Business

& Loss

Lossstatement)

statement)

BusinessIncome

Income (Attach

(Attach Profit

Profit &

$______________________

Disability

(Attach

award

letter)

Disability

(Attach

award

letter)

$______________________

Public Assistance

Assistance (Attach

Public

(Attachaward

awardletter)

letter)

$______________________

Other

Other

income

income(source):

(source): Dividends,

Other

income

Other income (source):____________________________

$______________________

interest, child

support,interest,

alimony,child

tips,

(source):

Dividends,

commissions,

etc.tips,

(Attach

support,

alimony,

Dividends, interest, child support, alimony, tips, commissions, etc.

(Attach documentation supporting other income)

documentation

supporting

commissions,

etc.

(Attach other

income)

documentation

supporting other

income)

TOTAL INCOME

INCOME

TOTAL

$______________________

F.F.APPLICANT'S

MONTHLY

EXPENSE. If EXPENSE.

monthly expenses exceed monthly income, an explanation must be provided (please attach separately):

APPLICANT'S

MONTHLY

If monthly expenses exceed monthly income, an explanation must be provided (please attach separately):

Mortgage/Rent (Attach copy of annual mortgage statement/rent agreement/receipts)

$______________________

Alimony/Child Support

Paid to:

(Please provide documentation of 3 months of payments)

$______________________

Name:

Name:

Name: __________________________________________________________

Address:

Address:

Address: _________________________________________________________

Telephone: _______________________________________________________

Telephone:

Telephone:

Telephone:

Groceries

Groceries

Groceries

$______________________

Utilities(Attach

(Attach

documentation

of 3 months

Utilities

documentation

of 3 months

of bills)of bills)

$______________________

Medical

(Attach

copy ofcopy

outstanding

bills not paid by

insurance)

Medical

(Attach

of outstanding

bills

not paid

$______________________

by insurance)

Insurance (Attach copy of statement for auto, health, life, homeowners, etc.)

$______________________

Auto Expenses (Include car payments, gas, maintenance receipts)

$______________________

Installment Payments (Attach copy of statements)

$______________________

Other

(Explain) (Attach

(Attach

Other Expenses

Expense (Explain)

Other Expenses (Explain) (Attach

documentation

documentation supporting

supporting other

other

documentation supporting other

expenses)

expenses)

expenses)

Other Expenses (Explain) ____________________________

(Attach documentation supporting other expenses)

TOTAL

MONTHLY

EXPENSES EXPENSES

TOTAL

MONTHLY

TOTAL

MONTHLY

EXPENSES

TOTAL MONTHLY EXPENSES

DHCS 6195 (8-07)

3

$______________________

$______________________

State of California¡ªHealth and Human Services Agency

Department of Health Care Services

G. APPLICANT'S ASSETS AND DEBTS

REAL ESTATE (Include personal residence, vacation property, etc. Please attach copy of annual mortgage statement. If

monthly payment is made, it should be accounted for in Section F.)

Address

city/county/state/zip):

Mortgage

Current

Value:

Mortgage

Balance:

Address

(include(include

city/county/state/zip):

Mortgage

Holder: Holder:

Current

MarketMarket

Value:

Mortgage

Balance:

Address (include

Mortgage Holder:

Current Market Value:

Mortgage Balance:

city/county/state/zip):

BANK

BANK ACCOUNTS

ACCOUNTS (Including

(Including Savings

Savings && Loans,

Loans, Credit

Credit Unions,

Unions, Certificates

Certificates of

of Deposit,

Deposit, Individual

Individual Retirement

Retirement Accounts.)

Accounts.)

BANK ACCOUNTS (Including Savings & Loans, Credit Unions, Certificates of Deposit, Individual Retirement Accounts.)

Account Number:

Number:

Account

Name of Institution & Address:

Account Number:

Name

Name of

of Institution

Institution && Address:

Address:

Type of Account (checking, savings, etc):

etc.):

Type of Account (checking, savings, etc):

Balance:

Balance:

Balance:

LIFE INSURANCE & ANNUITIES (Monthly payments should be listed in Section E if income, and/or Section F if expense)

LIFEINSURANCE

INSURANCE

& ANNUITIES

(Monthly

payments

listed inESection

E and/or

if income,

and/or

Section F if expense.)

LIFE

& ANNUITIES

(Monthly

payments

should should

be listedbe

in Section

if income,

Section

F if expense.)

Name

of Company:

Name

of Company:

Policy

Number:

Policy

Number:

Name of Company:

Policy Number:

CREDIT

CARDS

payments

CREDIT

CARDS

(Monthly (Monthly

payments should

be listed in should

Section F.)be

CREDIT CARDS (Monthly payments should

be in

listed

in Section

F.)

listed

Section

F.)

Name of Credit Card, Bank, etc.:

Total Amount Owed:

Name

Nameof

ofCredit

CreditCard,

Card,Bank,

Bank,etc.:

etc.:

Total Amount Owed:

Total Amount Owed:

MOTOR

VEHICLES

all cars,

trucks,

motorcycles,

boats,

recreational

vehicles

- Paid

forbeor

not.

Monthly

MOTOR

VEHICLES

(Include (Include

all cars, trucks,

motorcycles,

boats,

recreational vehicles

- Paid

for or not. Monthly

payments

should

listed

in Section

F.) payments

MOTOR VEHICLES (Include all cars, trucks, motorcycles, boats, recreational vehicles - Paid for or not. Monthly payments should be listed in Section F.)

should be listed in Section F.)

Year, Make, and License Number:

Year,

Year, Make,

Make, and

and License

License Number:

Number:

Date Purchased:

Current Value:

Date Purchased:

Date Purchased:

Current Value:

Current Value:

Loan Balance:

Loan Balance:

Loan Balance:

OTHER ASSETS (Miscellaneous items you own or are currently buying, e.g., stocks, bonds, etc.)

OTHER ASSETS (Miscellaneous items you own or are currently buying, e.g., stocks, bonds, etc.)

OTHER ASSETS (Miscellaneous items you own or are currently buying, e.g., stocks, bonds,

etc.)

Description:

Description:

Description:

DHCS 6195 (8-07)

Date Purchased:

Current Value:

Date Purchased:

Date Purchased:

Current Value:

Current Value:

4

Loan Balance:

Loan Balance:

Loan Balance:

State of California¡ªHealth and Human Services Agency

Department of Health Care Services

H. ATTACHMENTS/DOCUMENTATION/CERTIFICATION

All of the information requested in the application is voluntary; however, failure to completely

and accurately provide the information may result in a denial of the waiver application. Any

errors or omissions in the information provided by the applicant, that would affect the

Department's decision, may be a basis for denial of the request for hardship waiver. If

applicable, attach a copy of:

1. The most recent real estate sales contract or listing agreement.

2. The deed(s), registration(s), order determining succession, Affidavit of Death of Joint

Tenant, life estate or trust documents.

3. Applicant¡¯s most recent annual mortgage statement and/or rental agreement/receipts.

4. A current appraisal of estate property (including name of appraiser and license number).

5. The Will, Trust, or other court documents showing the names of all the heirs and the

percentage of the estate each will receive.

6. A certified estimate by a licensed contractor for any work that is necessary to make the

property habitable or marketable.

7. Applicant¡¯s most recent federal and state income tax returns.

8. Payroll stubs or other proof of monthly-earned income.

9. The most recent Profit & Loss Statement from business(s).

10. Documentation/receipts of any bills you paid on behalf of the decedent after their death.

11. The decedent's bank statement at the time of death.

12. Applicant¡¯s bills/statements substantiating medical bills, insurance bills, installment

payments.

13. Documentation/substantiation for meeting the hardship criteria. (Section C.)

14. Statements verifying expenses such as burial expenses, out-of-pocket administration

expenses (taxes, insurance, maintenance, etc.).

15. Copies of annuity, life insurance, and/or pension documents.

16. Written medical substantiation from a licensed health care provider(s), which clearly

indicates that the level and duration of care provided prevented or delayed the decedent

from being placed in a medical or long-term care institution.

17. Documentation or evidence that the applicant who provided care to the decedent resided

in the decedent¡¯s home during the period care was provided and continues to reside in

the decedent¡¯s home.

18. A denial letter(s) from the financial institution.

Certification

I understand that the statements I have made on this application are subject to investigation

and verification. I declare under penalty of perjury, that the statements I have given on this

form, to the best of my knowledge, are true and correct.

Signature of Applicant (Person applying for Waiver)

Signature of Applicant (Person applying for Waiver)

Signature of Applicant (Person applying for Waiver)

Print or Type Full Name

Print or Type Full Name

Print or Type Full Name

Telephone Number

Telephone Number

Telephone Number

(

DHCS 6195 (8-07)

5

Date

)

Signature

ofof

Person

Completing

(If different

from above)

Number

Signature

Person

Completing

Form

(If different

from above)

orName

Type

Name Telephone

Telephone

Number

Print

or Full

Type

FullFull

Name

Signature

of Person

Completing

Form

(if differentForm

from above)

Print

orPrint

Type

Telephone

Number

(

Date

Date

)

Date

Date

Date

 ................
................

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